Outcome of standardized treatment for patients with MDR-TB from Tamil Nadu, India.

Background & objectives Programmatic management of MDR-TB using a standardized treatment regimen (STR) is being implemented under the Revised National Tuberculosis Control Programme (RNTCP) in India. This study was undertaken to analyse the outcomes of MDR-TB patients treated at the Tuberculosis Research Centre, Chennai, with the RNTCP recommended 24 months STR, under programmatic conditions. Methods Patients failed to the category II re-treatment regimen and confirmed to have MDR-TB, were treated with the RNTCP's STR in a prospective field trial on a predominantly ambulatory basis. Thirty eight patients were enrolled to the trial from June 2006 to September 2007. Results Time to culture conversion was two months or less for 82 per cent of patients. Culture conversion rates at 3 and 6 months were 84 and 87 per cent respectively. At the end of treatment, 25 (66%) were cured, 5 defaulted, 3 died and 5 failed. At 24 months, 30 (79%) patients, including 5 defaulters, remained culture negative for more than 18 months. Twenty two (58%) patients reported adverse drug reactions (ADRs) which required dose reduction or termination of the offending drug. No patient had XDR-TB initially, but 2 failure cases emerged as XDR-TB during treatment. Interpretation & conclusions Outcomes of this small group of MDR-TB patients treated with the RNTCP's STR is encouraging in this setting. Close attention needs to be paid to ensure adherence, and to the timely recognition and treatment of ADRs.

Increased yield of smear positive pulmonary TB cases by screening patients with > or =2 weeks cough, compared to > or =3 weeks and adequacy of 2 sputum smear examinations for diagnosis.

BACKGROUND: RNTCP recommends examining three sputum smears for AFB from Chest Symptomatics (CSs) with cough of > or =3 weeks for diagnosis of Pulmonary TB (PTB). A previous multi-centric study from Tuberculosis Research centre (TRC) has shown that the yield of sputum positive cases can be increased if duration of cough for screening was reduced to > or =2 weeks. Other studies have shown that two smear examinations are adequate for diagnosis of smear positive PTB . To validate the above findings, a cross sectional multi-centric study was repeated in different settings in five geographical areas in India. METHODS: Three primary and secondary level health facilities with high out-patient attendance were selected from two Tuberculosis Units (TU) in each of the 15 selected districts to screen about 10,000 new adult outpatients from each state. For patients who did not volunteer history of cough, symptoms were elicited using a structured simple questionnaire. All the CSs were referred for sputum examination. RESULTS: A total of 96,787 out-patients were registered. Among them 69,209 (72%) were new adult out-patients. Using > or =2 weeks of cough instead of 3 weeks as the criterion for screening, there was an overall increase of 58% in CS and 23% increase in the detection of smear-positive cases. Among 211 patients, 210 were positive at least by one smear from the initial two specimens. Increase in the work-load if 2 smears were done for patients with cough of > or =2 weeks cough were 2 specimens (i.e. 13 to 15) per day for an adult OPD of 150. CONCLUSION: The yield of sputum positive PTB cases can be improved by screening patients with > or =2 weeks cough and two specimens are adequate for diagnosis.

Management of multi drug resistance tuberculosis in the field: Tuberculosis Research Centre experience.

SETTING: Multi-drug TB resistant (resistant to isoniazid and rifampicin) patients identified from a rural and urban area. OBJECTIVE: To study the feasibility of managing MDR TB patients under field conditions where DOTS programme has been implemented. METHODS: MDR TB Patients identified among patients treated under DOTS in the rural area and from cases referred by the NGO when MDR TB was suspected form the study population. Culture and drug susceptibility testing were done at Tuberculosis Research Centre (TRC). Treatment regimen was decided on individual basis. After a period of initial hospitalization, treatment was continued in the respective peripheral health facility or with the NGO after identifying a DOT provider in the field. Patients attended TRC at monthly intervals for clinical, sociological and bacteriological evaluations. Drugs for the month were pre-packed and handed over to the respective center. RESULTS: A total of 66 MDR TB patients (46 from the rural and 20 from the NGO) started on treatment form the study population and among them 20 (30%) were resistant to one or more second line drugs (Eto, Ofx, Km) including a case of "XDR TB". Less than half the patients stayed in the hospital for more than 10 days. The treatment was provided partially under supervision. Providing injection was identified to be a major problem. Response to treatment could be correctly predicted based on the 6-month smear results in 40 of 42 regular patients. Successful treatment outcome was observed only in 37% of cases with a high default of 24%. Adverse reactions necessitating modification of treatment was required only for three patients. IMPLICATIONS: Despite having reliable DST and drug logistics, the main challenge was to maintain patients on such prolonged treatment by identifying a provider closer to the patient who can also give injection, have social skills and manage of minor adverse reactions.

Course of action taken by smear negative chestsymptomatics a report from a rural area in south India.

Objective: To evaluate adherence to diagnostic algorithm of Revised National Tuberculosis Control Programme (RNTCP) and course of action taken by smear-negative chest symptomatics (CSs). Method: Interviewing smear-negative chest symptomatics. Results: Of the 423 smear-negative CSs interviewed, 85 (20%) were not prescribed antibiotics and only 133 (39%) received it for more than seven days. Of the 148 patients with persistence of symptoms, 83 (56%) returned for further investigations and only 39% were X-rayed. Main reasons for not returning were: ‘not aware’ or ‘consulted another health provider.’ Conclusion: Strict adherence to diagnostic algorithm and proper counselling of patients are important for diagnosing smear-negative pulmonary tuberculosis (PTB) cases.